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Brief Reports

Indian Pediatrics 2000;37: 187-189

Pediatric Parenteral Nutrition: South African Model and its Relevance to the Developing Countries

S.K. Chowdhary, M. Chitnis, S. Chowdhary, F. Gossen, C. Lazarus

From the Departments of Pediatric Surgery and Pediatrics, East London Group of Hospitals, University of Cape Town, South Africa.

Reprint requests: Dr. S.K. Chowdhary, Assistant Professor, Department of Pediatric Surgery, PGIMER, Chandigarh 160 012, India.

E-Mail: sujitchowdhary@hotmail.com.

Manuscript received: February 12, 1999;

Initial review completed: April 19, 1999;

Revision accepted: August 19, 1999

 


Pediatric parenteral nutrition is a powerful support system which has been around for nearly three decades(1). This is still unavailable in most major teaching hospitals in developing countries(2). The need for parenteral nutrition is most acutely felt in managing a surgical neonate.

The conventional mode of administration of parenteral nutrition entails central venous access for delivery of high concentration dextrose and use of syringe pumps for delivery of amino acids and fat emulsion. The whole system is based on an excellent pharmacy support, specialised nursing, and availability of syringe pumps. All these may be outside the reach of most hospitals in the developing world.

In South Africa, in the midst of world class hospitals in the cities, the remote townships have hospitals which resemble teaching hospitals in 

developing countries, yet parenteral nutrition has been effectively used for babies in these hospitals for nearly two decades. Standard `All in One' bags are available containing 250 ml of parenteral nutrition fluid preserved at 2-8°C and transported by air courier on demand by FAX from outsourcing pharmacy in three main cities (Cape Town, Johannesberg, Durban) to any hospital in the country. A retrospective study was undertaken to evaluate the efficacy of `All in One' parentral nutrition in a Neonatal Surgery Center supplied by an admixing unit situated 800 miles away and examine its relevance to the developing world.

Subjects and Methods

All surgical babies who were administered parenteral nutrition between November 1996 to November 1997 were included in the study. Each baby received the same standard formulation ITN 1601 containing (Nitrogen 0.78g, Glucose 26g, Fat 4g, Na+ 4.15 mmol, K 3.70 mmol, Mg 0.12mmol, Cl 8.60mmol, PO4 1.40mmol, Ca++ 2.20mmolm Soluvit, Peditrace, and Vitalipid) with energy value 0.7 Cal/ml. The data pertaining to all the babies relating to name, gestation, weight, diagnosis, days of parentral nutrition, venous access, complication were recorded on a database and analyzed.

Parenteral nutrition was administered on a fixed protocol to all babies. All babies who had a fasting period greater than 5 days were started on parenteral nutrition. Initially, one third of the days fluid requirement was administered as parenteral nutrition fluid and the rest as Neonatolyte. The second day this was increased to two third and full volume was administered as parenteral nutrition by day three. It was taken off at the same rate when 50% of enteral feeds were being tolerated.

Blood monitoring was simple and included hemoglobin, serum electrolytes, creatinine on a biweekly basis, liver function tests once weekly and trace elements were monitored only after first three weeks.

Results

During the study period 160 neonates underwent surgery for various congenital anomalies. All neonates were operated by residents under consultant supervision. Eighty six babies underwent surgery for gastrointestinal anomalies. Twenty eight babies were put on parenteral nutrition during the same period. The mean gestation period of the babies in this group was 34 weeks with a range 28-41 weeks. The average birth weight was 2.6 kg with a range of 1 kg_3.4 kg. The mean days of parenteral nutrition usage was 12 days with a range of 7-28 days. The outcome of surgical neonates operated and put on parenteral nutrition is shown in Table I.

Table I__Outcome of Surgery on 28 Newborn Babies who Received `All in One' Parenteral Nutrition.
Duodenal atresia 4 All alive, on follow up
Jejunal atresia  2 Both alive, on follow up
Ileal atresia 3 All discharged well, 1 died at 3 mo
Malrotation  5 5 All alive, on follow up
Examphalos major 1 Died of respiratory failure on post op D 28
Gastroduodenal duplication  1 Alive, on follow up
Necrotising enterocoloitis 6 2 died, 4 on follow up
Diaphragmatic hernia 2 Both alive and on follow up
Gastroschisis 4 All alive, on follow up

In all babies parenteral nutrition was started by peripheral cannula. In 7 babies it was changed to percutaneous sialastic long line on day 2-3 of parenteral nutrition. In one baby because of inaccessible peripheral vein, open internal jugular central line was placed. In line filters were used only for the central lines. Two babies developed severe extravasation injury on the dorsum of the hand with superficial gangrene. One of them needed excision and split skin grafting.

All the babies were monitored on the fixed protocol, no gross electrolyte abnormalities were noted. None of the babies developed cholestatic jaundice during the study.

None of the babies gained weight during the period of nutritional support, but all surviving babies maintained their birth weight. All the surviving babies were followed up for a period of 3 months to 1 year. One baby with jejunal atresia died in the late follow up with metabolic complication of short bowel syndrome. Twenty four babies were growing and gaining weight satisfactorily.

Discussion

The South African model was developed in the background of two highly publicised outbreaks of neonatal deaths related to contaminated parenteral nutrition solutions mixed within the hospital based admixing units(3). International standards and procedures for aseptic production of parenteral nutrition solutions demand a sterility assurance of the probability of contamination being less than 1: 1000(4).

The current method adopted in that country entails sterile mixing under total isolation in specially constructed isolater (La Calhene, France). Container surfaces are first disinfected with peracetic acid vapor. Amino acids and dextrose are mixed followed by lipid emulsion. The final product is agitated and gamma irradiated. The sterility assurance achieved by this techniques is 100 times higher than the lowest acceptable international sterility assur-ance limit(5).

The program is based on the philosophy of administering short term (1-3 weeks) main-tenance calories rather than aiming for growth. Peripheral venous access is used initially. There is centralisation of resources to prepare standard neonatal bag containing 250 ml. These bags have a shelf life of about 10 days and can be stored in the ward refrigerator. The resting energy expenditure in newborns have been reported between 30-50 Cal/kg(6). This fluid therefore supplies more calories than the resting metabolic demand.

The simple standard `All in One' bag parenteral nutrition was supplied with 48 hours on request and no metabolic complication was noted in any case. Although, no special nutri-tional assessment was done during the period of study, the preservation of birth weight after surgery in each baby and successful outcome is in itself documentary evidence of value of nutritional support in surgical babies. Effective nutritional support was available to the surgical babies without a nutrition team, admixing unit in the hospital, specialised neonatal nursing and need for central lines. The problems which have prevented utilisation of parenteral nutrition support in neonates in developing countries are well known. In this context the simple and effective South African model appears to be an attractive option.

References

1. Wilmore DW, Dudrick SJ. Growth and development of an infant receiving all nutrients by a vein. JAMA 1968; 203: 8660-8684.

2. Mahajan JK, Bagga D, Chadha R, Sharma A, Kumar A. Gastroschisis: A seven year review. JIAPS 1998; 3: 42-47.

3. Rothberg AD. Lessons from the investigations into intravenous fluid related deaths. South African Med J 1992; 1: 397-398.

4. Koornhof HJ, Isaacson M, Saunders MT, Wyk van CJ, Kotze AF, Rosekilly IC. Gamma irradiation of parentral solutions. J Clin Pharm Ther 1994; 19: 249-256.

5. Du Plessis TA, Rosekilly IC. The radiation enhancement of the sterility assurance levels of sterile fluids_A case study. Rad Phys Chem 1995; 46: 611-615.

6. Pierro A, Carnielli V, Filler RM. Partition of energy metabolism in the surgical newborn. J Pediatr Surg 1991; 26: 581-586.

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